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FOR OFFICE USE: �.� 3 + �� tta- <br /> APPLICATION FOR`SAN_ ITATION PERMIT <br /> s X '______ Permit No. 7�---------`� <br /> ---------------------------- <br /> `� (Complete in Triplicate) - i <br /> '' This Permit Expires 1 Year From Date Issued Date Issued <br /> -----------_-------------____________ ___________________ <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein <br /> described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION -- L_--4s��_^Y-, f� CENSUS TRACT -------------------------- <br /> Owner's Nama �°-�__I---------------- -- ------------Phone <br /> Address 3r �t " .- ,/ � --- ------ City w / F/4X-!�'' --- -- --- <br /> r �, <br /> -..- ::_ <br /> Contractor's Name _VJ.1 __ License, �___ Phone <br /> ----------------------------- <br /> Instailation will serve: ResidenceApartment House❑ Commer4ial []Trailer Court ',❑ <br /> Motel ❑Other ------------------------------------------ <br /> g g />(-9--_ Lot Size ._ <br /> - Number of living units:_____.__ Number of bedrooms �______Garba e Gririder - �,��.%�-------- <br /> Water Supply: Public System and name 'f �f_ �-- ... 6_______________________________Private ❑ <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam .E] <br /> Hardpan ❑ Adobex Fill Material ------------ If yes,type ____________________________ <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public,sewer✓ available within 200 feet,) v <br /> PACKAGE TREATMENT { ] SEPTIC-TANKX Size- _t�____________________ Liquid Depth's ''' <br /> Capacity/.� ______ Typ;,a0_f- 4-7__ Material�Q?+�®" �___ No. Compartments �------------ - <br /> ,/ <br /> ;Distance to nearest: Well __-______________---------Foundation __________ Prop. Line _ � <br /> - ----- <br /> _LEACHING LINE' No. of Lines ---' �_____________ Length of each line__,9._i ---_________.______ Total Length f�4p__.------------ <br /> � b <br /> 'D' Box�,.� <br /> r .11 _��__ Type Filfier'Mat� l�-" _ _ --ria -= epth Filter Material �Q- ------------------�---........ l <br /> -� Distance to nearest: Well __� '.___.______ Foundation Zf-_ ____________ Property Line, _ ______________ <br /> ­_�01 �-- __ Number __.___ Rock Filled Yes No <br /> SEEPAGE PIT ,(/J Depth -_ '___ ___ Diameter ______________ Cj <br /> f. I <br /> Water Table Deptht_______________________Rock Size_"'-____ <br /> ------------------ <br /> Distance to nearest: Well .__fir_____---------------Foundation -/�------------ Prop. Line --Qo:r-----______-__ } <br /> REPAIR/ADDITION(Prev, Sanitation Permit# ---_------_--------•-__- ---------------- Date --------------------.-__-_________1 <br /> Septic Tank (Specify Requirements) ----------- ----------------------------------------------- ----------------------------< --------------------------- <br /> Disposal .Field (Specify Requirements) ---------- -------------------------------------------------- -- <br /> ------------------------------------------------------------------------f--- '-------------- - ---------------------------------------- -------------------------------------------- -- <br /> t <br /> i <br /> `- ------------------------------� - - -------------------------------------------------------- - - - ----- - <br /> (Draw existing and required addition on reverse side) <br /> I <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licen- <br /> sed agents signature certifies the following- <br /> "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed ----------------- --------------/ ------------------------------------- Owner <br /> 00001- <br /> By �- Title c 'rte -- -------- <br /> (I her than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ---------------------------------------------------------------------------DATE //--7.____-._)___e.-_-7 <br /> BUILDING PERMIT ISSUED -------------------------------------/------------------- <br /> DATE -----------------------------------(----'.n <br /> ADDITIONAL COMMENTS ------------------------------- ---------------------------------------------------------------- <br /> ---- - ------------------------------------------------ <br /> -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ------------------------------- <br /> - -------- --- - - --- - - - - -- <br /> -- <br /> ---------------------------- -- -- -------- - <br /> ----------- - - ---- -- - ------------ - - <br /> - -------- -- <br /> Final Inspect[on Inspection by: ------------ - --- - -------Dat -. ---- -- ---- <br /> -- -- ------L-- <br /> SAN JOAN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev, 5M <br />